Ageism directed to older adults in health services: A scoping review

Objective: to map the expressions of ageism directed to older adults in health services and the respective coping measures. Method: a scoping review of primary studies in English, Spanish and Portuguese, without time delimitation and collected from 14 databases. Selection of the titles, abstracts and full text was in charge of two independent and blinded reviewers, totaling a corpus comprised by 41 articles. Data extraction was performed by pairs. The data were presented in narrative summaries and charts. Results: the ageism expressions are understood at the interpersonal level through images and attitudes that depreciate, devalue life and delegitimize older adults’ needs, as well as at the institutional level, which confers barriers to accessing health services, generating non-assistance and neglect. The coping measures consist of educational interventions and expansion of communication channels between aged people, health professionals and managers. Conclusion: the results may make health professionals vigilant for care/neglect guided by age bias and sensitive for coping with ageism by obtaining diverse scientific knowledge. The analysis of the phenomenon in the Unified Health System context constitutes a knowledge gap, as well as the implicit ageism expressions.


Introduction
The term "ageism" was first used to refer to disquiet, revulsion and aversion on the part of young and middleaged people towards aging, illness, disability, impotence, "uselessness" and death, and is usually linked to people because of their age (1) .Currently, it is recognized that ageism can be directed at any age group; however, up to the present day, the focus on older adults has received more attention since, in Western contexts, it is common for them to be represented as frail, weak, dependent, non-productive and whose health problems are naturalized and understood as a normal part of aging (2) .
The literature treats ageism as a multifaceted concept, which involves three different dimensions: cognitive (stereotypes); affective (prejudice); and behavioral (discrimination).The cognitive dimension encompasses negative stereotypes about aging.They are acquired very early in life and tend to act as self-fulfilling prophecies in old age (3) -for example, thinking that old people are incapable of learning new things.Stereotypes are activated when there is certain disregard for the specificities of aged people; they can generate labels that mean separating people into different categories and activating beliefs that depreciate individuals and cause negative consequences in different life areas (4) .
The affective dimension (prejudices) consists of an emotional reaction or negative or positive feelings that create differences in groups or outside them.For example, when a person feels sorry for older adults for considering them frail, which motivates disregarding their ability to do something alone; and behavioral, which comprises the discrimination that occurs when exclusionary practices are used towards third parties and these individuals are placed in unfavorable social positions due to age; for example, when an aged worker is prohibited from attending a training session on account of age (1) .Ageism can be subtle and hardly noticed or explicit and well known, shaping older people's perception of their abilities and needs, as well as the view of those around them (2) .
With the COVID-19 pandemic, previously veiled discussions became explicit, such as aged people's social place and the manifestation of ageism expressions by different sectors of society.In this scenario, aged people were portrayed as a social and family burden, frail, stubborn, disobedient and whose lives are devalued and considered less important than that of young people, which in turn causes implications older adults' mental, emotional and physical health (5) .
In the context of health services, the effects of stereotypes, prejudices and discrimination experienced by aged people are well-known and restrict access to health care, diagnoses and treatments, in addition to being significantly associated with worse health conditions, indicating reduced longevity, low quality of life and well-being, health risk behaviors, poor social relationships, physical illness, mental ailments and cognitive impairment (4) .Furthermore, ageism is expressed in the health field through biased and veiled attitudes and practices related to age, which favor younger people over older people in the use of health resources and services, such as access to beds in Intensive Care Units, high-cost treatments and surgical interventions, among others.It is present at the cultural level of Western societies and, at the institutional level, it refers to laws, rules, social norms, policies and protocols that restrict aged people's opportunities with important repercussions on the health care provided to this population group, in addition to potentiating inequalities in health systems and services (6) .Furthermore, ageism is less studied than other forms of discrimination, with few studies that explicitly examine its manifestations in the health field (7) ; in addition, there is scarce scientific evidence that supports health professionals' work process to mitigate the impacts of ageism in old age (8) .

That said, this review differs from what has already been
produced by presenting an expanded overview of how ageism manifests itself in health services.
Mapping the diverse evidence of ageism in health services and the respective coping strategies becomes relevant due to the possibility of providing subsidies for future studies, contributing to the formulation of policies and implementing strategies to reduce this phenomenon in the health field, in addition to helping train health professionals.
A preliminary survey was carried out in February 2021 with the Medical Subject Headings (MesH) terms "ageism" and "health", in the Prospero, PubMed, Open Science Framework, Joanna Briggs Institute Evidence Synthesis and Cochrane Database of Systematic Reviews portals, not finding scoping review studies on the topic.
Thus, this study aims at mapping the expressions of ageism directed to older adults in health services and the respective coping measures.

Type of study
This is a scoping review conducted in accordance with the methodology proposed by the Joanna Briggs Institute (JBI) for scoping reviews (9) , presented according to the recommendations set forth in the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension

Data collection instrument
An instrument for data extraction organized in a Word (2013) file was prepared, developed by the JBI (9) and adapted to meet the objectives of this review, tested by the research team that and dealing with diverse information regarding identification of the studies: authors, title, year of publication, Digital Object Identifier (DOI) link, journal, publication date, objectives, methodology (type of study, participants, context, concept, research instruments) and results (expressions of ageism and respective coping measures).

Data collection
An exploratory search was performed in February 2021 in PubMed and CINAHL via EBSCO to identify articles on the subject matter.The keywords found in the titles, abstracts and MeSH descriptors found were selected to comprise the search strategies developed with the support of a librarian specialized in reviews and applied in the databases selected as scenarios for this study (Figure 1).

Data treatment and analysis
The data extracted were organized in the MaxQDA software, which is part of the QDA family (Qualitative Data Analysis Software), 2020 version, and analyzed based on simple descriptive statistics, presented in narrative summaries and charts and discussed in the light of other national and international findings on the topic.

Ethical aspects
The studies used offer public domain access, waiving the need to submit the study to the Research Ethics Committee.

Results
The final sample of the review consisted of 41 scientific articles, which are presented in the PRISMA-SrC flowchart (12) in Figure 2.  The characterization of the scientific production on ageism directed to older adults in health services is presented in Figure 3.  think, feel and act when it comes to age and aging (54) .

Reference
Added to this social emphasis landmark is the countries' commitment to deal with ageism, reasserted in the United Nations Decade for Healthy Aging (2021-2030) on December 14 th , 2020, based on the 10-year action plan: Global strategy/action plan on aging and health (2016-2030); 2030 Agenda for Sustainable Development.

Both were endorsed in August 2020 by the World Health
Assembly and in December 2020 by the United Nations General Assembly (55) .Thus, prevention and confrontation of ageism has become one of the United Nations' four priority action areas.This movement has been reflected The theme of aging in contemporary times has generated intellectual and political concerns in capitalist societies, not only because it constitutes a demographic phenomenon but also because it involves economic, social, political, cultural and ethical aspects of significant commotion, which determine the quality of societies' commitment to human rights.In this context, current dualities can be seen: if on the one hand human/population aging represents a breakthrough in medicine/public health -combined with a culture of respect for differences guaranteed by rights and public policies, on the other hand, the increase in the number of aged individuals in society is seen as an impediment to economic growth -a paradox with opposing logics of profit versus human needs (56) .
In this sense, the Neoliberal logic that devalues the most aged maintains the propagation of negative images and attitudes about older adults, a scenario that is transposed into health professionals' daily work in services, through the development of stereotypes (thoughts), prejudices (feelings) and discrimination (action), which are expressed at the interpersonal and institutional levels and permeate health professionals' work process (7,57) .
Interpersonal ageism comprises prejudiced attitudes towards the aging process, including self-directed ageism (1) .This was evidenced in the results of this study based on the expressions manifested in the way health professionals act during care provision through anti-aging behaviors based on beliefs and stereotypes that affect the quality of the health care provided to older adults, such as: brief anamnesis (21,24) ; fewer guidelines on treatments or guidance with language that is not understandable or childish (34) ; embarrassment when caring for aged people (35,41) ; transfer of the care responsibility to the family (37) ; unconcern with lack of privacy, and unequal, inhumane, disrespectful treatment that disregards the specificities and vulnerabilities of old age (37,42) ; and negative perception about the treatment and about the aged person as a whole (23,25,32,(47)(48)51) .
Family relationships are decisive for interpersonal ageism (5) , a context in which the function of cultivating beliefs, values and principles that constitute the culture of a group is exercised, at the same time, in which younger people respond to the demands of liquid society.The adjective "liquid" gathers characteristics of contemporary individualistic society, with little solidarity, weak community ties, competitive, focused on the speed to perform tasks and on indiscriminate consumption of products, a scenario widely publicized on social networks and communication channels (58) .
As a result, we experience an exclusionary society with frequent intergenerational conflicts, whose stigmatization takes place in family interactions through attitudes of discredit, contempt and use of derogatory adjectives, assimilated by older adults, and which conform to self-image and a deteriorated identity.Therefore, separation or abandonment by the family is common, especially in situations of physical difficulties that require greater attention and protective care (59) .
All these ageism expressions, mapped by this review, reveal that older adults are considered a burden for society and held responsible for the increase in the public budget disputed both by labor and by capital.Despite all the ageism expressions, the aged population will still suffer from the highest rates of public and private neglect, as well as social discrimination, poverty and violence (60) .
Although the objective reality of population aging results from improvements in access to technological and health resources, the subjective reality of age stereotypes moves in a negative direction, which promotes inequalities, illness and exclusion, and which can be partially explained by the multibillion-dollar anti-aging industry that promotes stigmatization by placing supposed attributes of the old into a category that must be fought against and that should be avoided at all costs (61) .This is reflected in the assistance received in the health services, when the professionals, due to having negative views of old age and aging, use these perceptions to provide care, even unconsciously.
Although directly related to interpersonal ageism, institutional ageism differs from it by involving the inclusion of age principles in formal rules and procedures and in broader institutional cultures (7) , which does not necessarily require intention or awareness of bias against older adults, as the existence of such institutional prejudice is frequently not recognized and the institution's rules, norms and practices are longstanding, turning it into a phenomenon of social coercion.The consequence of the latter is natural acceptance, in which there is hardly room to criticize, disturb or modify, resulting in implicit and explicit effects of this phenomenon (62) , as impacts on the physical and mental health, social well-being and economy of older people, families and society (57) .
In addition, it is possible that institutional ageism favors labeling people according to their age, depersonalizing them and disregarding their subjectivity and specificities.
The ageism expressions presented in this review denote how devalued aged people can be when accessing health services and how chronological age can undervalue the assistance provided to them, while creating barriers in accessing health resources such as surgical interventions (17,24,36,39,52) , rehabilitation services (21,40) , drug Rev. Latino-Am.Enfermagem 2023;31:e4020.
The repercussions of ageism are also reflected on the nature of the care received by aged people's relatives, who tend to receive less psychological support regardless of the clinical outcome (38) , and which can impose new and intense challenges when it comes to older adults with some dependence degree or who need long-term care.This happens because the absence of a network to protect and defend rights leads aged people to face serious problems in their everyday lives and the most burdened end up being family members of care-dependent older adults, in particular (56) .
In health and long-term care institutions, ageism is ubiquitous, socially accepted, mostly undetected and heavily institutionalized; it is extremely detrimental to health and well-being, associated with poorer performance in physical and cognitive tasks, poorer physical and mental health, slower recovery from disability and decreased longevity; it also influences social values and shapes the research and politics focus, including how problems are conceptualized, the solutions proposed and how institutions develop and implement rules and procedures (57) .
In view of this, it becomes necessary that coping strategies are permanent and continuous, and that they are implemented top-down (from society to the individual) and bottom-up (from the individual to society, considering the role of aged people), with the joint objectives of reinforcing conditions that promote positive age images and mitigating conditions that promote negative age stereotypes (61) .This is because the evidence shows that higher knowledge levels about aging are associated with fewer anti-aging attitudes (47) .
During the training processes, future health professionals are trained to treat and achieve results through hospitalization, timely treatment of diseases, and considering age as an isolated health/disease marker (45) .
Although many needs of aged people can be met by interdisciplinary care in the Primary Health Care context, the tenuous linkage of actions to the social determinants in health shows professionals' difficulties to move away from biomedical care, which is purely repetitive, towards comprehensive and interactionist care, reiterating the hospital perspective, specialized and circumscribed to the disease, which strengthens historical and hegemonic paradigms in Brazil (63) : old age is a life stage in which the subjects' development is completed, and that losses and frustrations prevail in the face of physical decline, despite having experience and wisdom (64) , reinforcing negative connotations and reflecting pejorative stereotypes that establish disease as an intrinsic condition of old age (45) .Therefore, it becomes necessary to analyze age in the context of physical functioning, associated diseases, life expectancy, cognitive capacity, functional independence and nutritional status, among other important indicators that support the recommendation of appropriate treatments (49) .More reflective approaches, focusing on aged people's needs and on the integration of the age variable in analyses of the human being's life cycle, in the approach to the physiological aspects of aging and in expanded geriatric-gerontological assessments (46) , are essential for centralized care in health promotion and in the prevention of risks and health problems, considering older adults and their social, family, economic and cultural contexts.
It is also necessary to recognize the presence of ageism in health environments (45) so that health professionals become self-monitoring regarding practices guided by stereotypes, prejudices and age discrimination and that the management of health services encourage and implement educational interventions among health professionals to raise awareness and sensitize them about fighting against ageism in health services.
Another struggle front evidenced in the results of this study is related to the funding of age-related research studies and projects, to the creation of educational campaigns for public awareness about age, aging, old age and ageism (51) , and to the dissemination of aged people's rights and duties to empower and stimulate emancipating strategies in communities, churches, social groups, local councils for older adults' rights, universities open to aged people, neighborhood associations and collectives.
Ageism is a topic little known by the population in general, and the results of this review contribute not only to raising the discussion on the subject matter but also to advance scientific knowledge and innovate, by showing how age-related stereotypes, prejudices and discrimination are expressed in the health services' routines, revealing how unequal and unfair the assistance received by aged people can be in the contexts where they should be cared for.
The limitations of this study consist in the identification of the ageism expressions in health services explicitly reported by the authors of the articles analyzed, in addition to the fact that some reviewers did not obtain full texts, even after requesting them from the authors.

Conclusion
Ageism directed at older people in health services is manifested by negative expressions of discrimination,

Figure 2 -
Figure 2 -Flowchart corresponding to the selection process of primary studies included in the scoping review.Feira de Santana, BA, Brazil, 2021

Figure 5 -
Figure 5 -Mapping of the coping measures against ageism directed to older adults in health services.Feira de Santana, BA, Brazil, 2021 Araújo PO, Soares IMSC, Vale PRLF, Sousa AR, Aparicio EC, Carvalho ESS. on scientific productions, where an increase in the development of research studies can be observed from 2001 onwards.